Area emergency departments face daily challenges

For those that work in the emergency departments at area
hospitals, every day is different.

One day, it's relatively slow, with mostly minor injuries or
illnesses, and the next day, there are more critical patients
demanding treatment. It's those kinds of daily changes that makes
handling emergency rooms difficult and puts plenty of extra
pressure and tension on the staff.

"It's unpredictable work," said Lisa Lewis, vice president and
chief nursing officer at Holy Spirit Hospital in Camp Hill. "You
don't know what kind of patients are coming in or how many of them
will be in. That's part of the work that people in the ER kind of
like, but it is tough. You just can't predict it."

That may be doubly problematic if there isn't enough staff to
handle the surprise emergency cases during the week.

Carlisle Regional Medical Center recently came under fire from
the state Department of Health, which released a report indicating
that the hospital was working with a short-staffed emergency
department when two patients died in the first full week of
June.

CRMC CEO John Kristel disputes that the two were related and is
working with the Department of Health to institute a plan of
action, which DOH will approve and post to its website, as it did
with the initial report.

Kristel said in an interview with The Sentinel Thursday that
staffing for nurses in general has been something of a challenge
over the last few years.

"Obviously there's a challenge with nursing shortage that our
country and state have faced for some time," he said. "What we're
able to get is qualified people.

"We just hired an ED nurse director, Matthew Stapleton, who will
start in September. We're excited about bringing him in. We have
both nurses and physicians who are covering the Emergency Room
24/7. It's staffed by qualified personnel. It's a 365-day
operation."

Kristel didn't have a breakdown of how many physicians and
nurses are staffed at what times, but the DOH report says there are
often four registered nurses on staff during the evening shift,
though usually anywhere from one to three nurses may be off that
shift with no other employee to fill the vacancy.

Nursing
shortage

Holy Spirit has also felt the effects of the nursing shortage,
but staff members say they've been able to retain a good number and
haven't had to hire too many to fill vacant positions over the last
few years.

"We do very well with our nursing staff," Lewis said. "There is
a national nursing shortage that's been talked about for years. But
we've been able to hire good nurses and retain our staff. There
are, of course, people who get married or have children and leave,
and we do have to replace them, but we've had very good luck."

"We have very, very talented people and flexible nurses," added
Rick Shaffner, chief operating officer at Holy Spirit. "When we're
really in a bind, they immediately respond and come in. I've never
seen more dedicated nurses than the ones we have here."

Dr. Dana Kellis, senior vice president of medical affairs and
chief medical officer at PinnacleHealth, attributed some of the
staffing difficulties to the fact that ER nurses are generally hard
to replace.

"What does come up is that it takes several weeks to turn a
general nurse into an ER nurse," he said. "That makes it difficult
to replace ER nurses."

"There is more training involved specifically for the emergency
department," Lewis explained. "They have a whole lot of general
knowledge. When you have nurses in the operating room, they have a
very specific set of things they know. In the emergency department,
nurses have to have a lot of knowledge about a wide variety of
things."

Waiting time

No matter what the shortage is, however, the hospitals have
goals to make sure all patients are treated in a timely manner.

In 2009, Penn State Hershey Medical Center completed Phase 1 of
its redesigned emergency department, and by doing so, it created a
no-waiting arrival area where physicians and nurses triage patients
- an evaluation the determines the urgency of the case - in various
areas according to the severity of their injuries.

With that model, between 2009 and 2010 the number of
left-without-treatment patients had dropped to less than one-half
of 1 percent, according to Hershey Medical Center.

Though other area hospitals still require a longer wait for the
majority of patients, some of them are trying to get to that zero
waiting time.

"Patients walk in and they're brought right to the back," Lewis
said. "They're put in triage and we initiate care. There's some
paperwork, but that doesn't happen right up front. Usually a
clinical person sees them first.

"I'm looking at our data from our most recent days in July," he
said last week, "and the average waiting time was 1.4 minutes. We
try to help every patient once they arrive."

Kellis explained that because of the unpredictability of the
emergency department, it's not always possible to get patients out
of the waiting room at their goal time of 15 minutes.

What they do have, though, is a way to make sure that no one is
staying over two hours.

"If it gets to two hours, we call an emergency room alert, where
the vice president and the managers get on a conference call and
talk about the situation and how they can take the pressure off so
people can be seen more quickly," he said. "It's a two-hour
self-imposed limit that works in real time whenever it
happens."

Staffing

Part of making sure that people are treated as soon as possible
is to see that the proper amount of people are staffed at the right
times. Though there are quite a number of question marks when it
comes to what physicians and nurses will see in a day, hospital
officials know what times of the day are the most important to keep
an emergency department well staffed.

"There are days and times that are busier than others," Kellis
said. "Usually the day after the holiday is very busy, maybe
because people tend to indulge in more risky behavior - like
overeating - that catches up with them. Mondays are busy just
because of the weekend activities. When there's a major event, that
generates a bit more patients than normal.

"We try to match physicians' schedules to different times of the
day," he continued. "We're usually busiest during the 3-to-11
shift, when most people are getting off of work. We have up to four
physicians in the emergency room at that time. Between 7 to 9 a.m.,
there aren't a lot of people, so we'll only have one physician.

"Our nursing complements our physician staff. I don't have exact
numbers on hand, but we have a number of nurses staffed in the ER.
We also have mid-level physician assistants in addition to the
physicians."

Holy Spirit and CRMC also see very similar situations at their
own emergency departments.

"Based on how it is historically, there's not a lot of people
there earlier in the morning," Lewis said. "We have three
physicians in the afternoon. There's not a lot of variation on days
of the week, but the afternoon time is usually busy. It starts up
around 9 to 10 to 11 o'clock.

"That's how it's worked everywhere I've ever worked," he added.
"Usually it's people coming in after work or who are up in the
daytime, which is when accidents and emergencies happen."

"The evening hours tend to be the busiest," Kristel agreed.
"Folks are coming back from work or coming home from school, and
some primary care physician offices are not available in the
evening hours. So if they feel like the need to seek medical care,
they come to the ER."

The busier times may get busier, too, when ambulances from
across the region start calling in with critically ill and injured
patients. Those who are waiting in the waiting room may be forced
to wait even longer when an emergency case is called in.

"The most critically injured or ill patient in the ER will have
the highest priority," Kristel said. "The less severe problems will
have to wait. I don't mean to say that they're less important. A
sore throat in a child can be a problem and parents should seek
medical treatment, but when we have someone with a myocardial
infarction, that takes a higher priority."

Always a
challenge

Whatever plans hospitals have in place to keep the waiting time
down and the staffing up, they do note that there will always be a
challenge with emergency departments because of the way it meets
and treats patients.

"There are a lot of variables with the emergency department,"
Kristel said. "It's an ER, not a physician's office. There are all
kinds of variables that drive those (patient) numbers."

"Like any ER, the job can get overwhelming," Kellis said. "There
are 10 ambulances, and we get a lot of walk-ins. It's a challenge
not knowing what will come in."

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(8) comments

no matter what they do carlisle hospital ain't going to change, i was there 3 weeks ago with a infection in my foot, waited 1 hour in the waiting room, they clamed that the rooms was all full, when i went back only 3 rooms was full, then finally got in the back waited another 2 hours in the room, and wasn't one nurse or doctor that came back to check on me, so i got up and walked out, wasn't waiting anymore, that's why now i go to holy spirit, now better service, and better doctor's

Triplehhh....You are a liar. Anyone who has gone to CRMC knows that you cannot just walk out of the ER. There is a security door that can only be opened by one of the employees there. You are required to leave by the payment desk and they would not just let you walk out without checking with them. So you are making this up.

Our toddler waited for 4 hours on a weekday evening (a slow one apparently) for five stitches to be applied to a cut. The hospital charged our ins. company $2500 for 15 minutes' time on a bed, a cold compress, and some antiseptic. The doctor charged $1000 for 10 minutes' time with a needle and thread. The wait didn't justify the cost by any measure.

I’d like to see an article about the Patient Safety board/ committee that Carlisle Regional has and what they actually do and how often they meet. Are there any community members on it that are registered nurses? I’d like to know what that committee plans to do or change in light of the Dept of Health Report. I'd like a interview from one of them.

Using the excuse of nursing shortage—CRMC has/had very few job openings for nurses on their website or advertising in the newspaper for years.

We understand ER’s have unpredictability; higher levels of severity are treated first. What was CRMC’s issue was a pattern of inadequate staffing. Like one employee said you can’t fill empty slots with staff that don’t exist -meaning they did not have adequate staff to begin with.

I support the nurses as they likely were giving all they could to the hospital and they still wanted more by frequently calling them to come in for extra shifts. These workers have lives & families too. They need rest-time.

PastisPrologue i am lieing, first thing i didn't go through the security door, i walked out of the nurses office when you first get taking back, and no i ain't making it up, yeah a nurse and a doctor tryed to stop me but it didn't work, there's nothing they can do if you refuse treatment, that's on you then if something happens to you, the hospital is for the birds anyways, that's why 2 people died and the last past weeks? is that why a doctor and a nurse is having a law suit?

so i guess i am lieing bout that when its all over tv and the newspaper, that's pretty sad when a doctor and a nurse work there is putting the hopital down, but yet they build this hospital to be better? no it didn't get better it just got worse, they dont save peoples lives, they kill them!!!

NAOMI-I strongly urge you to practice some responsible journalism and report on the plight of several new nursing school grads in your area that cannot find a job, yet the CEO of this hospital wants to cite the "existing nursing shortage" for this whole debacle. Shame on you Mr Kristel.

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